Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: optical corporotomy and trans-corporeal resection, Shaeer's technique

IntroductionImplantation of a penile prosthesis in cases of neglected or resistant ischemic priapism, or delayed re-implantation following prosthesis infection and extraction, is usually a difficult and risky procedure due to fibrosis of the corpora cavernosa. Among the common complications are perforation of the urethra, tunica albuginea, and infection. The complications are usually due to the use of blind force against resistance.AimWe propose the techniques of Trans-Corporeal Resection and Optical Corporotomy as adjuvant measures for excavating the fibrosed corpora cavernosa under vision, without the use of force against resistance.MethodsSix patients with diffuse fibrosis of the corpora cavernosa were operated on. The instruments and technique are the same as for optical urethrotomy and transurethral resection. Optical Corporotomy was started with, where the corpora are incised from within. After establishment of a satisfactory passage, Trans-Corporeal Resection followed to scrape the fibrous tissue. Implantation of penile prosthesis was completed as usual. The procedure was performed through 1.5 cm incision in the tunica albuginea.Main Outcome MeasuresLength, girth, and straightness in the erect position, as well as the incidence of complications.ResultsOperative time was an average of 90 minutes. No difficulty was encountered during the procedure. No complications were noted through 1 year of follow-up.ConclusionOptical Corporotomy and Trans-Corporeal Resection allow for force-free, visually monitored excavation of the fibrosed corpora cavernosa, aiming at safer penile prosthesis implantation. Shaeer O, and Shaeer A. Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: Optical Corporotomy and Trans-Corporeal Resection, Shaeer’s Technique. J Sex Med 2007;4:218–225.     

Penile prosthesis implantation in cases of fibrosis: ultrasound-guided cavernotomy and sheathed trochar excavation

IntroductionImplantation of a penile prosthesis into fibrosed corpora cavernosa is a difficult and risky procedure. Specialized instruments that assist safer and more efficient excavation include Otis Urethrotome and various cavernotomes, all of which operate underneath the tunica albuginea, out of sight. The blind use of such instruments can result in perforation of the tunica albuginea or injury to the urethra.AimThis work describes the utility of ultrasonography for adding visual monitoring to any of the above-mentioned instruments, maintaining them in the mid-corpus cavernosum position to avoid perforation, and describes the application of alternative sheathed, sharp instruments that allow fast, efficient, and visually monitored drilling into fibrous tissue.Main Outcome MeasuresClinical outcome data were examined.MethodsSurgery was performed on five cases with extensive fibrosis of the penis. Initial blunt dilatation by Hegar dilators faced considerable resistance. An ultrasound probe was applied to the ventral aspect of the penis. A laparoscopy sheath was advanced under ultrasound guidance up to the fibrous tissue. A sharp laparoscopy trochar was inserted through the sheath. Its tip was oriented in the mid-corpus cavernosum by longitudinal and transverse sonography sections, as it drilled into the fibrous tissue. Laparoscopy scissors were used in the same fashion to cut fibrous tissue lumps. After full excavation, penile prosthesis was implanted.ResultsAll implants survived adequately. No complications occurred following implantation. Operative time ranged from 50 to 60 minutes. No difficulty was encountered at excavation.ConclusionUltrasound guidance can be a handy adjunct to any of the available techniques developed for excavating the fibrosed corpora cavernosa, with a possible decrease in difficulty and complication rate of the procedure. Utility of sheathed, sharp instruments guided by sonography is an alternative to the cavernotomes, allowing fast and efficient drilling into fibrous tissue. Shaeer O. Penile prosthesis implantation in cases of fibrosis: Ultrasound-guided cavernotomy and sheathed trochar excavation.     

Simultaneous Total Corporal Reconstruction and Implantation of a Penile Prosthesis in Patients with Erectile Dysfunction and Severe Fibrosis of the Corpora Cavernosa

IntroductionImplantation of a penile prosthesis in severely scarred corporal bodies represents a great challenge as fibrosis can compromise dilatation and subsequent closure of the corpora cavernosa and limit size, type, and function of the device.AimThe aim of this study is to report our experience of simultaneous corporeal reconstruction and penile prosthesis implantation in patients with severe penile contracture consequence of diffuse fibrosis.MethodsBetween March 2006 and February 2010, 18 patients with severe penile contracture and coporeal fibrosis underwent simultaneous corporeal reconstruction and placement of a penile prosthesis.Main Outcome MeasuresSurgical outcome and complications have been recorded during postoperative follow‐up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction questionnaire.ResultsAlthough the dilatation of the corpora was extremely difficult due to the severe fibrosis, a penile prosthesis has been implanted in all patients. A malleable penile prosthesis has been inserted in four patients and a three‐piece inflatable device in the remainder. After an average follow‐up of 26 months (range 6–36), revision surgery was required in four patients (elective exchange to three‐piece inflatable device in three patients and upsizing of the implant in one patient). Although all patients were able to achieve penetrative sexual intercourse, four patients were partially dissatisfied because of significant penile shortening.ConclusionIn expert hands, simultaneous penile prosthesis implantation and corporal reconstruction of severely scarred corpora yield satisfactory results. Patients must be warned that complication rate in presence of severe fibrosis is significantly higher than in virgin cases and that downsized cylinders might be required due to the contracture of the tunica albuginea. Sansalone S, Garaffa G, Djinovic R, Antonini G, Vespasiani G, Ieria FP, Cimino S, Loreto C, and Ralph DJ. Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa. J Sex Med 2012;9:1954–1961.     

Supersizing the Penis Following Penile Prosthesis Implantation

IntroductionFollowing implantation of a penile prosthesis, some couples are dissatisfied with penile length, girth, shaft, or glans engorgement. This may be delusional because of the procedure per se or preexisting risk factors such as neglected priapism, Peyronie's disease, radical prostatectomy, or overhanging suprapubic fat.AimIn this work, we try to enhance penile size in patients dissatisfied with its dimensions following implantation of a penile prosthesis, using various augmentation techniques.MethodsEighteen patients who have had penile prostheses implanted were enrolled in this study based on dissatisfaction with penile size. The complaint was relieved by counseling and administration of PDE5 inhibitors in seven patients. Two patients had elongation, girth augmentation, and glans injection; six had elongation and girth augmentation; and two had elongation and glans injection.Main Outcome MeasuresPenile size, satisfaction, and sexual function.ResultsAverage preoperative length and girth were 7.87 cm and 11.62 cm, respectively. Mean postoperative length and girth were 11.62 cm and 14.07 cm. The gain in length (47.6%) and girth (21%) were statistically significant (P < 0.005). All patients and partners were satisfied with the results following surgery except one who suffered graft loss.ConclusionImplantation of a penile prosthesis may improve penile rigidity, yet may confound couple's satisfaction with penile size to variable degrees. Sex education may alleviate those concerns. In refractory cases, penile augmentation may enhance phallic size and increase patient/partner satisfaction. Shaeer O. Supersizing the penis following penile prosthesis implantation.     

Combined Implantation of a Penile Prosthesis and Adjustable Continence Therapy ProACT in Patients with Erectile Dysfunction and Urinary Incontinence after Radical Prostatectomy: Results of a Prospective Pilot Study

IntroductionThe treatment of postradical prostatectomy erectile dysfunction (post-RP-ED) and stress urinary incontinence (post-RP-SUI) may require the combined implantation of a penile prosthesis and incontinence surgery. However, there is a lack of consensus regarding which incontinence surgery should be associated with a penile implant.AimsTo evaluate the combined implantation of a penile prosthesis and the adjustable continence therapy ProACT in patients with post-RP-ED and post-RP-SUI.MethodsWe implanted the ProACT device and a penile prosthesis synchronously (n = 6) and asynchronously (n = 4) in 10 patients with moderate post-RP-SUI and severe post-RP-ED. We evaluated the effects on urinary incontinence using the ICIQ and PGI-I scores and pad use. We evaluated the effect on sexual function using the EHS and Global Assessment Questionnaire (GAQ), and we evaluated satisfaction with the penile prosthesis on a 5-point scale. Postoperative pain associated with each procedure was evaluated by a numeric rating scale.ResultsNo cases of urinary retention or prosthesis infection were observed. Postoperative pain was mainly related to penile prosthesis implantation. After a mean follow-up of 22.7 ± 20.9 months (range: 6–53), significant improvements of the ICIQ score (15.3 ± 3.7 vs. 4.7 ± 2.3, P < 0.001) and pad use per day (2.8 ± 1.2 vs. 0.3 ± 0.5, P < 0.001) were observed compared with baseline. According to the PGI-I questionnaire, eight patients described a very much improved (n = 6) or much improved (n = 2) urinary condition. All patients declared an EHS = 4 with the use of penile prosthesis; all patients were very satisfied (n = 6) or satisfied (n = 4) with their penile prosthesis. All patients answered the GAQ positively.ConclusionThe combined implantation of a Pro-ACT device and penile prosthesis represents a feasible therapeutic option in patients with post-RP-SUI and post-RP-ED. The absence of postoperative pain associated with the ProACT procedure may represent the main interest in this therapy.     

A three-dimensional theoretical model of the relationship between cavernosal expandability and percent cavernosal smooth muscle

IntroductionPercent corporal smooth muscle content, a traditional predictor of corporal veno-occlusive function, is invasive and clinically assessed by histomorphometric analyses of erectile tissue biopsies. Cavernosal “expandability” which may be a more physiologically relevant parameter is a measure of work performed to achieve penile erection, and as a consequence, an indicator of the ability to approach maximum penile volume at low intracavernosal pressure.AimTo demonstrate that cavernosal “expandability” determined by noninvasive methodology can replace the determination of percent smooth muscle. To predict Young's modulus for the corpora cavernosa in rabbits and, this by inference, in humans; the latter facilitates the comparison of resistance to penile expansion presented by the tunica vs. cavernosal tissue.Main Outcome MeasureA refined three-dimensional formula for cavernosal expandability, defined as the negative reciprocal of the cavernosal bulk modulus in the semierect state, was derived as a function of percent corporal smooth muscle content, using principles of engineering mechanics of materials. The model included Young's modulus, E, for the corpora cavernosa as an unknown parameter.MethodsVolume-pressure data obtained from three groups of New Zealand white rabbits: (i) control group (N = 7); (ii) hypercholesterolemic group (N = 5) on 0.5%; (iii) atherosclerotic group (N = 8), was plotted, and compared with the model.ResultsData points of mean cavernosal expandability (0.012–0.017 (mm Hg)⁻¹) vs. percent trabecular smooth muscle content (33.9–45.4%) for the three groups of rabbits were analyzed. The revised model formula was fitted to the existing rabbit experimental data points producing a value of Young's modulus equal to 0.01 (MPa).ConclusionsRabbit cavernosal expandability can predict percent smooth muscle content. Cavernosal Young's modulus can be predicted. Further clinical research efforts to provide human data are needed. Luo H, Goldstein I, and Udelson D. A three-dimensional theoretical model of the relationship between cavernosal expandability and percent cavernosal smooth muscle. J Sex Med 2007;4:644–655.     

Efficacy and patient satisfaction associated with penile prosthesis revision surgery

IntroductionComplications that arise after placement of a penile prosthesis may result in the need for revision surgery. Few contemporary penile prosthesis series have focused solely on describing the efficacy and patient satisfaction associated with penile prosthesis revision surgery.AimTo determine the overall success of penile prosthesis revision surgery in providing the patient with a functional implant. Device efficacy and patient satisfaction with penile prosthesis revision surgery will be assessed using psychometrically validated instruments.Main Outcome MeasuresThe erectile function (EF) and satisfaction domains of the International Index of Erectile Function (IIEF) were used to quantify the overall efficacy and patient satisfaction with revision surgery.MethodsData were derived from a prospective database of consecutive patients undergoing penile prosthesis revision surgery performed by a single surgeon (B.R.K.). Eleven patients filled out the IIEF prior to surgery and 26 completed it following surgery.ResultsThirty-nine consecutive patients underwent 55 revision procedures related to a prior penile prosthesis. Thirty-four patients (87%) have a functional implant with a median follow-up of 6.5 months (range 1–42 months). Significant improvements in the overall IIEF, EF domain, and satisfaction domain were seen in those patients studied prior to and following revision surgery. The total IIEF, EF domain, and satisfaction domain of the IIEF for the group of 26 responders were 60.7 ± 19.3, 26.6 ± 8.7, and 15.7 ± 5.6, respectively. Patients with fibrotic corporal bodies scored significantly lower on the EF and satisfaction domains than did any other group.ConclusionsPenile prosthesis revision surgery is highly successful in providing men with a functional implant. The prostheses function well and patients are satisfied with their devices. Further study of those men with corporal fibrosis is warranted in order to determine the factors needed to improve their overall satisfaction with revision surgery. Kava BR, Yang Y, and Soloway CT. Efficacy and patient satisfaction associated with penile prosthesis revision surgery.     

Antibiotic patterns with inflatable penile prosthesis insertion

IntroductionA clear set of guidelines has not been defined in the use of antibiotics in penile prosthesis implantation.AimWe surveyed urologists throughout the United States to determine current practice patterns regarding antibiotic use in primary and revision penile prosthesis surgery.MethodsFifty-two Sexual Medicine Society of North America (SMS) member urologist and 164 non-SMS member urologist responses were obtained.Main Outcome MeasuresThe survey contained 10 questions regarding antibiotic selection for primary and revision inflatable penile prosthesis (IPP) implantation.ResultsOne hundred percent of responders in both groups utilize intraoperative antibiotics, most commonly vancomycin and gentamicin in both groups. Of SMS members, 94% prescribed postoperative home oral antibiotics in contrast to 88% of non-SMS members (P = 0.3). Among SMS members, the most common antibiotic prescribed postoperatively was levofloxacin 500 mg daily while among non-SMS members, the most common antibiotic postoperatively was cephalexin 500 mg 2–4 times daily. Of SMS members, antibiotic irrigation intraoperatively occurred with 100% and with 92% of non-SMS members (P = 0.04). Thirty-seven percent SMS physicians and 15% non-SMS physicians made modifications of intraoperative and postoperative antibiotics for high-risk patients (P = 0.001). In the circumstance of revision of a clinically noninfected IPP, 23% SMS and 16% non-SMS member physicians utilized additional antibiotics/treatment (P = 0.3). Sixteen of those surveyed admitted that they had been approached by their institution about their antibiotic use and asked to change. In the past 5 years, 29% surveyed have changed their practice patterns in antibiotic use.ConclusionsThere is significant difference between practice patterns of SMS and non-SMS urologists in terms of antibiotic irrigation usage, modifications for high-risk patients, and consensus about the importance of antibiotic use with Coloplast Titan implant (Coloplast, Minneapolis, MN, USA). A significant lack of uniformity exists among urologists performing prosthetic surgery with regard to antibiotic protocols. A standard set of guidelines may prove useful to implanters. Wosnitzer MS and Greenfield JM. Antibiotic patterns with inflatable penile prosthesis insertion.     

Trans-corporal incision of Peyronie's plaques

IntroductionPatients presenting with Peyronie's disease (PD) curvature and erectile dysfunction (ED) can achieve straightening and rigidity through penile prosthesis implantation and manual modeling and, if necessary, a relaxing tunical incision with or without grafting. Unfortunately, this maneuver will not correct PD‐induced shortening. In addition, incision and grafting after the prosthesis has already been implanted adds to operative time and risk, and may indicate mobilization of the neurovascular bundle and, possibly, a secondary skin incision.AimThis work describes trans‐corporal incision (TCI), a minimally invasive endoscopic approach for plaque incision from within the corpora cavernosa, restoring straightness and length to the penis, before calibration of the corpora cavernosa, allowing implantation of a longer prosthesis in a straight penis, with neither mobilizing the neurovascular bundle nor a secondary incision.MethodsSixteen patients with PD deformity and refractory ED were operated upon. Intra‐operative artificial erection demonstrated the deformity. Through a penoscrotal incision, the corpora were dilated. TCI was performed to incise Peyronie's plaques at the point of maximum deformity. Artificial erection was re‐induced and correction of curvature evaluated. Length was measured before and after TCI. Implantation proceeded as usual.Main Outcome MeasuresPenile straightness and length.ResultsFollowing implantation, the penis was straight in all cases. Pre‐TCI length of the corpora was unequal on either side. Post‐TCI, both corpora were of equal length with an average increase of 2.5 cm (11.9%) on the right side and 1.9 (9.1%) on the left.ConclusionTCI; corporoscopic incision of Peyronie's plaques upon implantation of penile prosthesis is a minimally invasive approach that restores both straightness and length to patients with PD and ED, with neither mobilization of the neurovascular bundle nor plaque incision and grafting. Shaeer O. Trans‐corporal incision of Peyronie's Plaques. J Sex Med 2011;8:589–593.     

Implantation of penile prosthesis in cases of corporeal fibrosis: modified Shaeer's excavation technique

IntroductionImplantation of penile prosthesis in case of corporeal fibrosis poses a greater risk of complications because of the blinded aggression involved. Penoscopic excavation and ultrasonography‐guided excavation can decrease these complications but still have limitations.AimThis work described the combination of penoscopy‐guided and ultrasound‐guided excavation in a trial to eliminate the limitations inherent to both.MethodsTwelve patients with penile fibrosis were operated upon. A guide wire was inserted under ultrasound monitoring, along which penoscopic corporotomy and resection was performed. Ultrasound was also used to monitor penoscopic excavation toward the tip of the corpus cavernosum and crus.Main Outcome MeasuresEase of the procedure, safety, extent of dilatation, and girth of prosthesis implanted.ResultsThe procedure was relatively easy. Ten cases were dilated up to size 13.5 Hegar, and two up to size 14. Size 13 prosthesis was implanted in all cases.ConclusionThe relative safety of the procedure, the low incidence of complications, the possibility of restoring length and girth to an extent, and the resultant generous dilatation of the corpora for accommodating a sizable unhindered inflatable penile prosthesis all make ultrasound‐guided penoscopic corporotomy and resection a valid option for prosthesis implantation in cases of penile fibrosis. Shaeer O. Implantation of penile prosthesis in cases of corporeal fibrosis: Modified Shaeer's excavation technique. J Sex Med 2008;5:2470–2476.     

Electrophysiologic activity of the tunica albuginea and corpora cavernosa: possible role of tunica albuginea in the erectile mechanism

IntroductionIt is claimed that the tunica albuginea (TA) shares in the erectile mechanism by compressing the emissary veins passing through it. However, the TA does not contain smooth muscle fibers.AimWe investigated the hypothesis that TA lacks a contractile activity on the emissary veins passing through it.MethodsFourteen healthy male volunteers (mean age 35.2 ± 4.3 years) were studied. The electromyographic (EMG) activity of the TA and corpora cavernosa (CC) was individually recorded in the flaccid and erectile phases by EMG needle electrodes. Recording was performed in the upper, middle, and lower third of the TA and CC on one and then on the contralateral side.Main Outcome MeasuresThe TA lacks a contractile activity on the emissary veins passing through it.ResultsThe EMG of the CC in the flaccid phase recorded regular slow waves and random action potentials. The wave variables in the erectile phase exhibited a significant decrease (P < 0.01) compared with the variables in the flaccid phase of the same subject. The TA EMG showed no electric waves in the flaccid or erectile phases. These recordings were similar from the upper-, middle-, and lower-third of the penis, and were reproducible from the contralateral CC.ConclusionsElectric waves were recorded from the CC in the flaccid phase; wave variables decreased at erection. In contrast, the TA showed no electric waves in the flaccid or erectile phases. It appears that the TA acts as a CC covering sheet which expands passively at erection, and shares in compressing the subtunical venular plexus between it and the tumescent CC. Shafik A, Shafik AI, El Sibai O, and Shafik AA. Electrophysiologic activity of the tunica albuginea and corpora cavernosa: Possible role of tunica albuginea in the erectile mechanism.     

A Review of Surgical Techniques for Impending Distal Erosion and Intraoperative Penile Implant Complications: Part 2 of a Three‐part Review Series on Penile Prosthetic Surgery

IntroductionMore than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.AimThe review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.MethodsA review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.Main Outcomes MeasuresThe article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.ResultsIntraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.ConclusionsThis review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon. Henry GD and Laborde E. A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: Part 2 of a three‐part review series on penile prosthetic surgery. J Sex Med 2012;9:927–936.     

The Relaxation Induced by Uroguanylin and the Expression of Natriuretic Peptide Receptors in Human Corpora Cavernosa

IntroductionReceptors for natriuretic peptides have been demonstrated as potential targets for the treatment of male erectile dysfunction.AimThis study investigates the relaxant effects of the atrial natriuretic peptide (ANP) and uroguanylin (UGN), and expression of natriuretic peptide receptors on strips of human corpora cavernosa (HCC).Main Outcome MeasuresQuantitative analysis of natriuretic receptor expression and relaxation of precontracted strips were used to assess the membrane-bound guanylate cyclase–cyclic guanosine monophosphate (cGMP) pathway in HCC strips.MethodsHCC was obtained from a cadaver donor at the time of collection of organs for transplantation (14–47 years) and strips were mounted in organ baths for isometric studies.ResultsANP and UGN both induced concentration-dependent relaxation on HCC strips with a maximal response attained at 300 nM, corresponding to 45.4 ± 4.0% and 49 ± 4.8%, respectively. The relaxation is not affected by 30 µM 1H-[1,2,4]oxaolodiazolo[4,3-a]quinoxalin-1-one (ODQ) (a soluble guanylate cyclase inhibitor), but it is significantly blocked by 10 µM isatin, a nonspecific particulate guanylate cyclase (pGC) inhibitor. UGN was unable to potentiate electrical field stimulation (EFS) or acetylcholine-induced relaxations. The potential role of pGC activation and cGMP generation in this effect is reinforced by the potentiation of this effect by phosphodiesterase-5 inhibitor vardenafil (55.0 ± 7.5-UGN vs. 98.6 ± 1.4%-UGN + vardenafil; P < 0.05). The relaxant effect was also partially (37.6%) blocked by the combination iberitoxin-apamin but was insensitive to glybenclamide. The expression of guanylate cyclase receptors (GC-A, GC-B, GC-C) and the expression of the natriuretic peptide “clearance” receptor (NPR-C) were confirmed by real-time polymerase chain reaction. The exposure of HCC strips to ANP (1 µM) and UGN (10 µM) significantly increased cGMP, but not cyclic adenosine monophosphate (cAMP) levels.ConclusionsUGN relaxes HCC strips by a guanylate cyclase and K_ca-channel-dependent mechanism. These findings obtained in HCC reveal that the natriuretic peptide receptors are potential targets for the development of new drugs for the treatment of erectile dysfunction. Sousa CM, Havt A, Santos CF, Arnaud-Batista FJ, Cunha KMA, Cerqueira JBG, Fonteles MC, and Nascimento NRF. The relaxation induced by uroguanylin and the expression of natriuretic peptide receptors in human corpora cavernosa.     

Historical Review of Penile Prosthesis Design and Surgical Techniques: Part 1 of a Three-Part Review Series on Penile Prosthetic Surgery

IntroductionThroughout history, many attempts to cure complete impotence have been recorded. Early attempts at a surgical approach involved the placement of rigid devices to support the natural process of erection formation. However, these early attempts placed the devices outside of the corpora cavernosa, with high rates of erosion and infection. Today, most urologists in the United States now place an inflatable penile prosthesis (IPP) with an antibiotic coating inside the tunica albuginea.AimThe article describes the key historical landmarks in penile prosthesis design and surgical techniques.MethodsThe article reviews and evaluates the published literature for important contributions to penile prosthesis design and surgical techniques.Main Outcome MeasuresThe article reviews and evaluates the historical landmarks in penile prosthesis design and surgical techniques that appear to improve outcomes and advance the field of prosthetic urology for the treatment of erectile dysfunction.ResultsThe current review demonstrates the stepwise progression starting with the use of stenting for achieving rigidity in the impotent patient. Modern advances were first used in war-injured patients which led to early implantation with foreign material. The design and techniques of penile prostheses placement have advanced such that now, more complications are linked to medical issues than failure of the implant.ConclusionsToday's IPPs have high patient satisfaction rates with low mechanical failure rates. Gerard D. Henry. Historical review of penile prosthesis design and surgical techniques: Part 1 of a three-part review series on penile prosthetic surgery. J Sex Med 2009;6:675–681.     

Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease

IntroductionPeyronie's disease, a localized fibrosis of the tunica albuginea surrounding the penile corpora, results in penile curvature and sexual dysfunction. Surgical management involving grafting to straighten the penis is the treatment of choice in conditions unresponsive to conservative therapy where penile length preservation is important.AimTo determine surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.Main Outcome MeasuresThe International Index of Erectile Function (IIEF), postoperative self-reports, patient satisfaction, and clinical characteristics were used to measure outcomes.MethodsWe retrospectively reviewed charts of 36 patients who underwent surgery for Peyronie's disease requiring grafting from 1999 to 2005. Follow-up to subjectively assess outcomes was conducted.ResultsAverage patient age at surgery was 55 ± 1 years. Body mass indexes were similar among all groups. Erectile dysfunction risk factors were comparable with 36% reporting hypertension and 22% hypercholesterolemia. Overall patient follow-up time was 673 ± 98 days. Self-reported resolution of penile curvature was noted in 60% of dermal, 100% of Tutoplast, and 76.9% of Stratasis graft recipients. Stratasis patients maintained presurgery length (54%) and rigidity (77%) more so than dermal (30%, 60%) and Tutoplast (23%, 39%) patients. Assessment of erectile dysfunction using the IIEF-5 captured significant improvements in patients receiving Stratasis grafts (preoperative: 10.1 ± 1.1 vs. postoperative: 17 ± 1.6). Overall, 89% of patients reported satisfaction following surgical intervention.ConclusionsSurgical management of Peyronie's disease results in correction of penile curvatures and high rates of patient satisfaction. Loss of penile length and decreased rigidity occurred to a lesser degree with Stratasis grafts. While detailed informed consent is essential in this patient population, novel materials such as Tutoplast and Stratasis grafts improve outcomes following surgical correction of Peyronie's disease. Kovac JR, and Brock GB. Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.     

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

IntroductionFifty‐two‐year‐old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse.AimErectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus.Main Outcome MeasuresOutcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix.MethodAn objective measure of the patient's erectile function was performed via penile Doppler.ResultsPenile Doppler after 10‐mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60–70% rigid erection.ConclusionsTo our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three‐piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse. Martinez DR, Mennie PA, and Carrion R. Erectile function significant enough for penetration during sexual intercourse after removal of inflatable penile prosthesis. J Sex Med 2012;9:2938–2942.     

Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation

BackgroundPenile prosthesis implantation in cases of severe Peyronie’s disease may require plaque excision/incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk.AimEvaluating transcorporeal debulking of Peyronie’s plaques by “Shaeer’s punch technique.”MethodsPenile prosthesis implantation and punch technique (PPI-Punch) was performed for 26 patients. After corporotomy and dilatation, Peyronie’s plaques were punched out from within the corpora cavernosa using the punch forceps, and then a penile prosthesis was implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed.OutcomesThe study outcomes were straightness of the erect penis, complication, satisfaction with length on a 5-point scale, the International Index of Erectile Function-5, and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire.ResultsAverage preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hyposthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009.Clinical ImplicationsThe proposed technique is minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss.Strengths & LimitationsOne limitation is the inability to accurately measure preoperative erect length in patients with erectile dysfunction with poor response to intracavernous injections.ConclusionShaeer’s punch technique is a minimally invasive procedure for transcorporeal excavation of Peyronie’s plaques before penile prosthesis implantation, omitting the need for mobilization of the neurovascular bundle or spongiosum, and hence, there is low or no risk for nerve or urethral injury and brief plaque surgery time.Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020;17:1395–1399.     

Changes in the Penile Arteries of the Rat after Fractionated Irradiation of the Prostate: A Pilot Study

IntroductionExternal beam radiotherapy for prostate cancer leads to erectile dysfunction in 36%–43% of patients. The underlying mechanism is largely unknown, although some clinical studies suggest that the arterial supply to the corpora cavernosa is responsible. Two animal experimental studies reported on the effects of a single fraction of prostate irradiation on the penile structures. However, irradiation in multiple fractions is more representative of the actual clinical treatment.AimThe present prospective, controlled study was initiated to investigate the effect of fractionated prostate irradiation on the arteries of the corpora cavernosa.Main Outcome MeasuresHistological evaluation of the penile tissue in comparison with control rats at 2, 4, and 9 weeks after irradiation.MethodsThe prostate of twelve rats was treated with external beam radiation in 5 daily fractions of 7.4 gray. Three control rats were treated with sham irradiation. Prostatic and penile tissue was evaluated for general histology (hematoxylin–eosin). The penile tissue was further evaluated after combined staining for collagen (resorcin fuchsin) and α-smooth muscle actin (SMA) (Biogenex).ResultsThe prostate showed adequate irradiation with fibrosis occurring at 9 weeks after irradiation. The corpora cavernosa showed arteries that had developed loss of smooth muscle cells expressing SMA, thickening of the intima, and occlusions. All the control rats maintained normal anatomy.ConclusionThis is the first animal experimental study that demonstrates changes in the arteries of the corpora cavernosa after fractionated irradiation to the prostatic area. The preliminary data suggests that erectile dysfunction after radiotherapy might be caused by radiation damage to the arterial supply of the corpora cavernosa. van der Wielen GJ, Vermeij M, de Jong BWD, Schuit M, Marijnissen J, Kok DJ, van Weerden WM, and Incrocci L. Changes in the penile arteries of the rat after fractionated irradiation of the prostate: A pilot study. J Sex Med 2009;6:1908–1913.     

Role of a novel tetrodotoxin-resistant sodium channel in the nitrergic relaxation of corpus cavernosum from the South American rattlesnake Crotalus durissus terrificus

IntroductionCoitus in snakes may last up to 28 hours; however, the mechanisms involved are unknown.AimTo evaluate the relevance of the nitric oxide (NO)-cyclic guanosine monophosphate (cGMP)-phosphodiesterase type 5 (PDE5) system in snake corpus cavernosum reactivity.MethodsHemipenes were removed from anesthetized South American rattlesnakes (Crotalus durissus terrificus) and studied by light and scanning electronic microscopy. Isolated Crotalus corpora cavernosa (CCC) were dissected from the non-spiny region of the hemipenises, and tissue reactivity was assessed in organ baths.Main Outcome MeasuresCumulative concentration-response curves were constructed for acetylcholine (ACh), sodium nitroprusside (SNP), 5-cyclopropyl-2-[1-(2-fluorobenzyl)-1H-pyrazolo[3,4-b]pyridine-3-yl]pyrimidin-4-ylamine (BAY 41-2272), and tadalafil in CCC precontracted with phenylephrine. Relaxation induced by electrical field stimulation (EFS) was also done in the absence and presence of N^ω nitro-L-arginine methyl ester (L-NAME; 100 µM), 1H-[1, 2, 4] oxadiazolo[4,3-a]quinoxalin-1-one (ODQ; 10 µM) and tetrodotoxin (TTX; 1 µM).ResultsThe hemipenes consisted of two functionally concentric corpora cavernosa, one of them containing radiating bundles of smooth muscle fibers (confirmed by α-actin immunostaining). Endothelial and neural nitric oxide synthases were present in the endothelium and neural structures, respectively; whereas soluble guanylate cyclase and PDE5 were expressed in trabecular smooth muscle. ACh and SNP relaxed isolated CCC, with the relaxations being markedly reduced by L-NAME and ODQ, respectively. BAY 41-2272 and tadalafil caused sustained relaxations with potency (pEC₅₀) values of 5.84 ± 0.17 and 5.10 ± 0.08 (N = 3–4), respectively. In precontracted CCC, EFS caused frequency-dependent relaxations that lasted three times longer than those in mammalian CC. Although these relaxations were almost abolished by either L-NAME or ODQ, they were unaffected by TTX. In contrast, EFS-induced relaxations in marmoset CC were abolished by TTX.ConclusionsRattlesnake CC relaxation is mediated by the NO-cGMP-PDE5 pathway in a manner similar to mammals. The novel TTX-resistant Na channel identified here may be responsible for the slow response of smooth muscle following nerve stimulation and could explain the extraordinary duration of snake coitus. Capel RO, Mónica FZ, Porto M, Barillas S, Muscará MN, Teixeira SA, Arruda AMM, Pissinatti, L, Pissinatti A, Schenka AA, Antunes E, Nahoum C, Cogo JC, de Oliveira MA, and De Nucci G. Role of a novel tetrodotoxin-resistant sodium channel in the nitrergic relaxation of corpus cavernosum from the South American rattlesnake Crotalus durissus terrificus.     

In Vitro Assessment of Antimicrobial Properties of Rifampin-Coated Titan® Coloplast Penile Implants and Comparison with Inhibizone®

IntroductionIt is a common practice to soak Titan® Coloplast penile implants in antibiotic solution prior to implantation.AimThe aim of this study is to identify an ideal solution for soaking the Titan® Coloplast penile implants prior to implantation.MethodsTitan® strips were soaked in a different combination of antibiotics and the zone of inhibition was studied against Staphylococcus epidermidis and Escherichia coli. This zone of inhibition was compared against zone of inhibition produced by Inhibizone®-coated silicone strips. Zones of inhibitions were also compared for different components of Inhibizone® implant such as cylinder, tubing, connector, rear tip extender, and reservoir, and compared with similar components of Titan® Coloplast penile implants.Main Outcome MeasuresThe zone of inhibition against S. epidermidis and E. coli for Titan strips dipped in Rifampin and Gentamicin was compared against other antibiotics. The clinical significance of dipping Titan®-coated Coloplast implant in Rifampin and Gentamicin solution was determined.ResultsRifampin 10 mg/mL + gentamicin 1 mg/mL (R10/G1) and rifampin 1 mg/mL + gentamicin 1 mg/mL (R1/G1) had excellent coverage against S. epidermidis and E. coli. The zone of inhibition (utilizing the Titan® coating) produced by both these solutions exceeds that produced by Inhibizone® by 40% to 56% for S. epidermidis and 33% for E. coli. Components of the American Medical System implant (tubing connectors and rear tip extenders) are not coated with antibiotics and had no zone of inhibition.ConclusionSoaking Titan®-coated Coloplast implants in R10/G1 solution produces a zone of inhibition greater than that produced by Inhibizone®-coated penile implants. The clinical significance of this increased zone of inhibition can only be determined by a separate clinical study. Dhabuwala C. In vitro assessment of antimicrobial properties of rifampin coated Titan®coloplast penile implants and comparison with Inhibizone®. J Sex Med 2010;7:3516–3519.